A case of vaginal recurrence following laparoscopic left-sided colon cancer resection combined with transvaginal specimen extraction.

Here, we presented a case of laparoscopic colon cancer resection who developed vaginal recurrence after transvaginal specimen extraction. To our knowledge, this is the first case report on natural orifice specimen extraction-site cancer recurrence. A 59-year-old female underwent laparoscopic left hemicolectomy due to left-sided colon adenocarcinoma, and the specimen was removed through the vagina. She was admitted to the hospital with the complaint of vaginal discharge after 1 year. Tumoural infiltration on the posterior vaginal wall was diagnosed, and biopsy was reported as adenocarcinoma. The patient underwent laparoscopic low anterior resection, total abdominal hysterectomy, bilateral salpingooferectomy and en bloc resection of the posterior vaginal wall due to the local recurrence of colon cancer. She had no recurrence or metastasis within the 3rd year after primary tumour surgery. Recurrence at the specimen extraction site after natural orifice surgery should be considered among the complications. For this reason, incision-preserving methods should not be neglected.

INTRODUCTION

Colorectal cancer is the third most common cancer worldwide and is the fourth leading cause of cancer-related deaths.[1] Surgery is usually the main treatment for colorectal cancers, and laparoscopic surgery for colon cancers has a widespread use with its advantages. Although the amount of incisions has been reduced by the laparoscopic method, the failure to reduce wound-related complications has caused investigation for new methods. This process has started with single-incision laparoscopic surgery and then has continued with natural orifice surgery. Several surgical resections were combined with the several natural routes. Nowadays, two natural routes are used to extract specimens in colon surgery. While the transanal route is often used for left hemicolectomy, rectosigmoidectomy and restorative proctocolectomy, the transvaginal route is usually used for large or proximal tumours.[2] In the literature, rectovaginal fistula, pelvic seroma, dyspareunia, pelvic pain and bladder dysfunction have been reported as major complications due to use of the transvaginal route.[3] However, no information has been available on vaginal recurrence of the cancer.

We aimed to present a case of laparoscopic colon cancer resection combined with transvaginal specimen extraction and the development of vaginal recurrence.

CASE REPORT

A 59-year-old woman presented with rectal bleeding. She had no comorbidities other than hypertension. Her body mass index was 26.5 kg/m2 and had no weight loss. Colonoscopy revealed an ulcerative mass at 20 cm above the anal verge. Biopsy result was reported as adenocarcinoma. There was no metastatic focus on radiologic screening. She was operated under general anaesthesia as American Society of Anesthesiologists Grade 2. Laparoscopic left hemicolectomy was performed with the help of five trocars. Side-to-side colorectal anastomosis was performed with an endostapler (60-mm blue cartridge). The stapler opening of the anastomosis was closed using a continuous 3-0 polypropylene suture. Subsequently, the specimen was removed through the posterior vaginal fornix without using an incision protector (the mass was macroscopically interpreted as not reaching to the serosa). The vaginal opening was closed with a 2/0 vicryl suture. The operation was terminated after anastomosis control by an air test. She had no significant post-operative complications and was discharged on the 6th post-operative day. Pathology result was reported as well-differentiated adenocarcinoma and T3N0M0 (Stage 2A). Surgical margins were reported as intact. Chemotherapy was not considered for the patient who returned to active life on the 15th post-operative day. One year after the operation, she was admitted to another hospital with the complaint of vaginal discharge. A 4.5 cm × 3.5 cm mass originating from the posterior vaginal wall was detected on the examination. Biopsy revealed an adenocarcinoma, and she was operated of the recurrence of colon cancer at another centre. The patient underwent laparoscopic low anterior resection, total abdominal hysterectomy, bilateral salpingooferectomy and en bloc resection of the posterior vaginal wall due to the recurrence of colon cancer. The specimen was removed from a suprapubic incision. Loop ileostomy was performed. She was discharged on the 5th post-operative day. The FOLFOX6 chemotherapy regimen was started to the patient. Ileostomy was closed after 6 months, and she had no recurrence or metastasis within the 3rd year after primary surgery.

DISCUSSION

Abdominal incision is the main cause of complications such as pain, infection and incisional hernia.[4] Minimally invasive methods are aimed at minimising the incision and reducing the complications associated with it. The reduction of trocar diameters and the removal of specimens from the body by natural routes have been first mentioned in appendectomy and cholecystectomy operations. Then, they have been begun to be applied in colorectal surgery.[5] In our clinic, a total of 174 laparoscopic colorectal resections were performed between 2013 and 2018 and 100 of them were removed through a natural orifice. The transvaginal route was used in 23 of the 100 patients. Only one patient had recurrence at the specimen extraction site. In this case, no incision protector was used for extracting the specimen. Several techniques such as skin drapes, specimen extraction bags and cleaning extraction site with a tumouricidal agent have been used to protect the incision site. A study examining cases of colon cancer undergoing transvaginal extraction described that 14% of studies on the right colon and 46% of studies on the left colon did not use an incision protector.[5] In a systematic review involving 41 studies, it was observed that no incision protector was used in 48% of them. Pathology result was malignant in 60% of studies which did not use an incision protector.[2] Nose surgery is not too much in the literature and long-term follow-up results are limited. Therefore they make it impossible to comment on the necessity and the suitable technique of the use of an incision protector. They make it impossible to comment on the necessity and the suitable technique of the use of an incision protector. However, our case has shown that an incision protector is required to be used even the tumour did not appear to reach the serosa.

In the literature, the rate of incisional recurrence in colon cancer surgery has been reported as 1% in open surgical techniques and up to 1.3%[6] in laparoscopic approaches. In our clinic, only 1% of colorectal cancer patients who underwent natural orifice surgery had incisional recurrence. In a study comparing the long-term outcomes of patients undergoing natural orifice surgery and conventional laparoscopy, it was found that there were no significant differences in local recurrence and disease-free survival between two groups.[7] Our case can attract attention because our patient has been the first case with recurrence at the specimen extraction site among patients undergoing natural orifice surgery. Although we are trying to minimise the complications related to the natural orifice surgery, our priority is oncological outcomes.

Incisional recurrence can be asymptomatic for a time and cannot be recognised until it becomes advanced.[8] Our case began to be examined due to the complaint of vaginal discharge and was found to have vaginal recurrence. For this reason, recurrence should be considered in patients with cancer who had transvaginal specimen extraction.

CONCLUSION

Natural orifice surgery that has recently attracted interest has some advantages. However, as in our case, it is necessary to be aware of such late-stage complications affecting the benefit–loss ratio and to take precautions for them. We think that such complications will be prevented by the use of incision-preserving methods now routinely used in our clinic.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.